Methods
Semi-structured individual interviews were conducted with GPs and registrars in Region Jämtland Härjedalen, a sparsely populated region in northern Sweden that includes an area somewhat larger than the Netherlands and that has around 127.000 inhabitants. There are primary health care centres spread throughout the region, with one hospital centrally located in the only town. Primary care plays a gatekeeper role in non-acute illnesses. Rectoscopies are performed in primary care at all of the region's health care centres, as are point-of-care FOBTs.[6] As in the rest of Sweden, GPs refer patients directly for bowel imaging; the referrals are all sent to the hospital's endoscopy or radiology departments. There is no CRC screening program. The faecal test that is used is an immunochemical FOBT (iFOBT), and the usual practice is to test three samples.
The participants were purposely selected. In the region 63 GPs and 26 registrars were eligible for the study. They were sorted into eight groups with respect to gender, length of professional experience, and distance from the workplace to the hospital. From each group one person was drawn. These persons were sent an invitation letter with information about the study and then contacted by telephone for further information; if they wanted to participate an interview was arranged. They were informed that the aim of the study was to explore what made the GPs suspect CRC and their practice, not to judge the way they handled the patients, and that there were no right or wrong responses. A topic guide was constructed before the interviews and then revised and supplemented after the first and second interviews. The interviews were performed face-to-face, audiotaped, and transcribed verbatim by one of the authors (CH). Each interviewee read their transcribed interview and was invited to make corrections and additions, none of them made any changes.
Initially, six GPs and two GP registrars were invited. Two of these declined to participate, referring to lack of time, and in their places two others were invited and interviewed. The interviews lasted from 20 to 49 (average 37) minutes. After analysing these eight interviews, we saw a need for additional interviews to confirm our findings; accordingly, we chose, invited and interviewed another three GPs. By the eleventh interview, data saturation seemed to be reached. To confirm this, supplementary telephone interviews were conducted with two of the first six GPs. Informed consent was obtained from all participants. Four of the GPs had less than ten (mean 4.5) years and five had more than ten (mean 25) years of experience of work as a GP. Five of the GPs worked at health care centres with a distance to the hospital of less than 25 (mean 9) kilometres, and four at health care centres with a distance of more than 25 (mean 67) kilometres. The registrars had a mean professional experience of 3.5 years after graduation and both had their workplaces less than 25 km from the hospital.
This study used qualitative content analysis with an inductive approach as described by Graneheim and Lundman.[20] The transcribed interviews were read thoroughly by all of the authors. The analytical process included naïve reading of the interviews to obtain a sense of the whole plus interpretation of the latent content of the interviews. CH first extracted and condensed meaning units for five of the interviews, then all authors discussed the result and agreed on further approach. Two of the authors then separately coded each interview; CH coded all the interviews and the other authors coded three or four interviews each. Categories were identified, and all codes were sorted into these, refining the categories during this process. A consensus on data saturation, codes, categories, and analysis was reached through group discussions that involved all authors. The categories are presented in the results section and are illustrated with quotes that are marked with individual numbers for each participant. Examples of the analytical process are presented in Table 1.
Ethical approval was obtained from the Regional Ethical Review Board, Umeå (Dnr 2013/326–31).
BMC Fam Pract. 2015;16(153) © 2015 BioMed Central, Ltd.
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